The crash site in Millbrook near Ballarat in September 2015. (Supplied: Air Transport Safety Bureau)
Aviation authorities have found a student pilot who lost control on her first solo navigation flight was not formally assessed on the autopilot function.
The 19-year-old RMIT student, who has never been publicly named, died in September 2015 when the Cessna she was flying in crashed into a Millbrook paddock, near Ballarat.
More the two years on, the Australian Transport Safety Bureau (ATSB) has released its report into the accident, finding the aviation student’s efforts to manually control the aircraft while it was in autopilot mode are likely to have led her to lose control and nose-dive into the rural property.
The ATSB’s executive director, Nat Nagy, said the crash raised serious concerns.
“It is now common for general aviation aircraft to be equipped with autopilot systems,” Mr Nagy said.
“And while these systems can be very useful, it is vitally important that pilots understand how the systems will react in different circumstances.
“If automation is not performing as expected, then the safest option under most circumstances is for them to disengage the system.”
The ATSB revealed it was not a requirement for trainee pilots to demonstrate knowledge of the autopilot and its limitations.
“The pilot’s underpinning knowledge of the autopilot system could not be ascertained due to the absence of formal assessment,” the report said.
In July 2017 the Civil Aviation Safety Authority introduced an element into the Flight Examiners Handbook, which requires pilots to demonstrate knowledge of the autopilot system when they are assessed for a Recreational Pilot Licence.
The ATSB also expressed concerns over the absence of warnings in the manufacturer’s manual for the Cessna 172 — commonly used as a primary training aircraft.
“It was likely that the inexperienced pilot was not aware of how the autopilot would react to manual control inputs,” the report stated.
“The inclusion of limitations, cautions and warnings in the aircraft documentation … would likely enhance pilot awareness of such situations.”
Autopilot warnings now included in manual
The flight training organisation involved in the young pilot’s aviation course with RMIT has updated its operations manual to include warnings about the operation of the autopilot system — warnings that are absent in the manufacturer’s documentation.
The avionics manufacturer, Garmin, told the ATSB that it was “common knowledge” for pilots not to manipulate the flight controls with the autopilot on.
RMIT has meanwhile amended its standard operating procedures to include a warning to pilots that loss of control is possible if a pilot tries to manually override autopilot.
The university said its community was “devastated” by the accident, and said “the ATSB report confirms that RMIT followed procedures and was operating within regulations, [but] out of respect for the family, we won’t be commenting on the report any further”.